| Personal Information |
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| First Name* |
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| Last Name* |
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| Street Address* |
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| City* |
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| State* |
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| Zip/Postal Code* |
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| Area Code + Phone Number* |
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| E-mail Address* |
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| Alternate E-mail Address |
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| Date of Birth* |
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Emergency Contact Information
(Someone who is not diving with you) |
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| Emergency Contact* |
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| Relationship* |
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| Emergency Contact Phone* |
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| Diving Insurance (Company & policy number) * |
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| (ie. DAN, Dive Assure, PADI, etc.) |
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| Dive Experience/history |
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| Certification level* |
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| Certification/Diver Number* |
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| Certification date for this level* |
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| Certification Agency* |
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| Date of Last Dive* |
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| No. of Logged Dives* |
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| Dives per year* |
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| Night Dives* |
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| Dives in Cozumel* |
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| Deepest Dive* |
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| Diving Package and Hotel Information: |
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| Arrival Date* |
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| Airline/Cruiseline* |
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| Flight Number/Ship Name* |
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| Flight/Ship Arrival Time* |
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| Departure Date* |
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| Flight/Ship Departure Time* |
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| Hotel* |
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| Number of Divers in Party* |
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| Package Request* |
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| Would you like to add a night dive? |
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| Would you like us to make your hotel reservations with one of our partner hotels? |
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| Equipment needs: (TANKS & WEIGHTS are included) |
| Will you need to rent equipment? |
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Would you like to dive air or nitrox?
(nitrox fills are $11 USD per fill)
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| Waiver and Policies |
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| Please read and initial the statements below by putting your initials in the field |
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| I have no known physical limitations or medical conditions that preclude me from diving. * |
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| I will avoid diving under the influence of alcohol or drugs. * |
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| I will adhere to the dive plan(s) given by the divemaster(s).* |
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| I will not exceed the maximum depth of the dive plan given by the divemaster(s).* |
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| I will surface with at least 500psi in my tank.* |
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| I will dive with the group at all times as required by the Marine park.* |
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| I understand that the reefs of Cozumel are within a protected marine park and I will follow all rules as set forth by the Marine park. I will not stand on, sit on, touch, or take hold of the reef or any marine life.* |
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| I have read, understand and agree to respect the cancellation policy of Blue XT~Sea Diving. * |
Cancellation policy |
| How did you hear about us? |
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| Additional Inforrmation/Comments/Requests |
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